Information and Instructions for Completing a Termination ...

1 Information and Instructions for Completing a Termination Notice (Completed form should be submitted to the PHS awarding agency Grants Management Office named in the Notice of Award). This form summarizes the Information to be supplied by (2) To record your payback status and service, you will Ruth L. Kirschstein National research Service Award receive from the sponsoring Federal agency an Annual (NRSA) recipients on Termination of their award and for a Payback Activities Certification (APAC) (PHS 6031-1). limited period thereafter. This form may also be used to form one year after your Termination date and annually document the Termination of appointments to non-NRSA thereafter until your service obligation has been individual and institutional research training programs completed.

2 ( , NIH intramural research training awards and T15. training grants), research education awards ( , R25), (3) You are required to keep the Federal funding agency and institutional career development awards ( , K12). informed of your current address and telephone number For non-NRSA recipients, please refer to specific until your total payback obligation is satisfied. Report any guidance on documenting the Termination of appointments change to the NRSA Payback Service Center, Office of in the Funding Opportunity Announcement, and in the Extramural Programs, National Institutes of Health, 6011. terms and conditions of the Notice of Award.

3 Executive Boulevard, Suite 206, MSC 7650, Bethesda, MD 20892-7650; (301) 594-1835; (866) 298-9371. ALL KIRSCHSTEIN NRSA RECIPIENTS. SPECIFIC Instructions FOR ITEMS ON THE. (1) The attached Termination Notice (PHS 416-7) serves Termination NOTICE. as the official record of your training under a Kirschstein NRSA. This summary of work accomplished, (Item 1) Self-explanatory. support period, stipends received, and post-training activity is required of all recipients immediately after (Item 2) Provide the complete grant or award number that Termination . After securing proper signatures, forward the supported your last year of research training, career completed form to the appropriate awarding office development, or research education, and for which this (National Institutes of Health (NIH) Institute or Center or Termination notice is being submitted ( , 5 T32 GM.))

4 Agency for Healthcare research and Quality (AHRQ)). 60654-08). (2) Because the sponsoring Federal agencies are asked (Item 3) Self-explanatory. periodically to review Kirschstein NRSA program impact (Item 4) The last four digits of your Social Security in terms of career choices, you may be contacted after the Number are requested under authority of the Public Health Termination of this award, but no more frequently than Service Act as amended (42 USC 288). This Information once every 2 years, to determine how the training provides the sponsoring Federal agency with Information obtained has influenced your career. vital for accurate identification and review of terminated appointments and fellowships and, where applicable, to KIRSCHSTEIN NRSA POSTDOCTORAL establish and maintain an accurate payback record file.

5 RECIPIENTS WITH A PAYBACK OBLIGATION Providing this portion of your Social Security Number is voluntary and you will not be deprived of any Federal (1) As specified in the Payback Agreement you signed at rights, benefits, or privileges for refusing to disclose it. the time of award, biomedical or behavioral health-related research , health-related teaching, and/or health-related (Item 5) Include the degree(s) sought or earned during the activities must begin within 2 years of terminating period of support and the date all degree(s) were (or are Kirschstein NRSA support; otherwise, unless an expected to be) completed. extension of the 2 year service initiation period or a waiver of the obligation is granted, financial payback becomes (Item 6) Self-explanatory.

6 Due. Further details are given in the Payback Agreement and the National research Service Awards section of the (Item 7) For Kirschstein-NRSA Awards Only -- Provide most recent version of the NIH Grants Policy Statement Information on your total Kirschstein NRSA stipend found at: If support under the parent fellowship or training grant of you have any questions, contact the awarding office that which the number in Item 2 is a part. For domestic non- supported your training. Federal institutions, the Amount of Stipend column must reflect the stipend only. Individual fellows sponsored by (training at) Federal or foreign institutions must include all money paid directly to them in the Amount of Stipend.

7 PHS 416-7 (Rev. 04/2020) Instructions column. Note the stipend amount must reflect only the may, in addition to other remedies available to the Kirschstein-NRSA stipend. Do not include any Government, subject me to civil penalties under the supplementation provided by other sources. Do not Program Fraud and Civil Remedies Act of 1986 (45 CFR. include any other NRSA-awarded costs such as tuition or Part 79). Also, if I have a payback obligation, I understand institutional allowance. that payback service must begin within 2 years of terminating my Kirschstein NRSA support; otherwise, (Item 8) Self-explanatory. financial payback becomes due, unless an extension of the 2-year service initiation period or a waiver of the (Item 9a) Please mark a single box under each of the obligation is granted.

8 I also understand that if I fail to repay three categories that best describes your anticipated post- both principal and interest, the Federal Government will award position, activity, and the organization with which take authorized actions to collect the debt. you will be affiliated. (Item 13) The sponsor of (for individual fellowship awards). (Items 9b and 9c) If you will be beginning a new position or the contact Program Director (for an institutional award). after the Termination of your appointment or fellowship must sign and date the form certifying that the research provide post-award title, address, and phone number, if training Information is correct.

9 Known. (Item 14) For Kirschstein-NRSA Awards Only -- A. (Item 10) For Kirschstein-NRSA Awards Only -- Provide business official of domestic non-Federal sponsoring contact Information for how you can be reached following institutions (with the knowledge and authority to verify this your Kirschstein NRSA training. Information ) must certify that the Information provided in Items 6 and 7 is correct according to institutional records. (Item 11) For Kirschstein-NRSA Awards Only -- Provide Information on prior support from any other Public reporting burden for this collection of Information is estimated to Kirschstein NRSA grants and awards or the NIH Loan average 30 minutes per response, including the time for reviewing Repayment Program.

10 If you received National Health Instructions , searching existing data sources, gathering and maintaining Service Corps (NHSC) scholarships for which you still the data needed, and Completing and reviewing the collection of have a service obligation, report the number of months of Information . An agency may not conduct or sponsor, and a person support. This Information will be used to develop a is not required to respond to, a collection of Information unless it complete service obligation record. displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of (Item 12) In signing this form, I certify that the statements Information , including suggestions for reducing this burden, to: NIH, therein are true and complete to the best of my Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, knowledge.